Research news and notes

1. Professionalism among residents is associated with knowledge and clinical skills 

One of the most important aspects of physician training is the effort to instill core professional values. Basic professionalism is expected of all physicians; however, it is difficult to teach and assess. A recent article in JAMA [4] presents a study that evaluated professionalism among internal medicine residents at the Mayo Clinic and tried to determine the characteristics of the most professional among the residents. Professionalism was evaluated by applying a “360°” questionnaire, asking all those who had meaningful contact with the residents (faculty, other residents, students, nonphysician professionals) to evaluate them. The responders were asked to evaluate multiple parameters as follows: integrity, level of communication, respect to others, desirability as a coworker, and others. In addition, the study had access to the residents' in-training examination scores and mini-clinical evaluation exercise (miniCEX) scores, as well as the number of didactic conferences attended and percentage of evaluations completed by each resident. The latter 2 measures were included to evaluate conscientiousness. Residents who scored in the top 20% on professionalism, according to the “360°” questionnaires, had higher scores on the in-training and miniCEX examinations. They also completed a higher percentage of evaluations of others, indicating conscientious behavior. The number of clinical conferences attended did not correlate with assessment of professionalism.

The findings of the study are intuitively expected; the best residents are usually good in many ways. Excellent medical knowledge makes clinical duties less stressful and the resident more relaxed and pleasant to others. On the other hand, conscientious students and residents are more likely to study diligently and thus, end up with better medical knowledge. The value of this article is mainly in presenting a way to measure and predict professionalism more objectively. The traditional residency training was an apprenticeship, where learning took place by imitation of the attending physicians and gradual accumulation of personal experience. Limits on resident work hours create an incentive to formalize resident education and increase its efficiency. In this framework, professionalism will need more specific attention than ever before.

2. Surgical training using simulation and systematic performance review 

The imperative to increase the efficiency of resident education is greatest among the surgical specialties. Urology appears to have made great advances in computer simulation and virtual reality training [5]. Recent examples include the development of a computer-enhanced systematic approach to teaching orchiopexy, a common pediatric urologic procedure [3]. The procedure was divided into 11 steps, and the resident was guided through each and tested on the performance of each step. A checklist tool was developed to objectively assess resident performance, and a log of postoperative feedback was used to structure deliberate practice. The method allowed for the testing of residents at their entry into the pediatric urology rotation and at the completion, documenting their rate of learning. This type of innovation in resident training is finally bringing physician education into the 21st century. Virtual reality training in endoscopic surgical procedures has been extended even to medical students with excellent success [2]. Thirty-two medical students at the University of Texas, Southwestern Medical Center (Dallas, Tex), were divided into 2 groups. Half were trained on the LAP Mentor (Simbionix, Cleveland OH) virtual reality simulator of a cholecystectomy, whereas the others were not. The students who were trained in virtual reality improved on all measures of surgical performance as evaluated by 2 observers, whereas the control students improved only on “knowledge of procedure.” The method still requires further validation, but the future trend is clear: if virtual reality training is available, there is no reason to allow the totally untrained to have their first experience with surgery on a live patient.

Many neurosurgical programs are small and have relatively limited resources. Neurosurgery encompasses extremely varied and complex procedures; therefore, although computer-assisted training and simulation are making inroads into neurosurgery, the progress is rather slow. What can we do in the meantime? Even without computer assistance and before any purchase of expensive equipment, we can enhance the surgical education of residents by insisting on meticulous preparation for each surgical case—which includes the making of a written surgical plan. After surgery, the resident must review the case, assess their own performance, and then receive detailed feedback from the attending physician. If limitations on work hours lower the number of surgical cases available to residents, we must make each operation count.

3. Creation of autologous motor neurons from cells of patient with amyotrophic lateral sclerosis 

The recent discovery of a method to revert adult human cells to a stem cell phenotype [6] holds enormous promise. In the August 29th issue of Science, Dimos et al [1] present another step toward a clinical application. The researchers obtained skin fibroblasts from 2 sisters, aged 82 and 89, who were having slowly progressive amyotrophic lateral sclerosis (ALS) and had the same mutation in the superoxide dismutase gene. About 30 000 fibroblasts were transduced, with genes encoding for the 4 factors previously shown to be essential and adequate for reprogramming adult cells to an embryonic stem (ES) cell-like state [6]. The resulting ES cells were grown on a layer of supporting cells in ES medium. They were identified, by DNA “fingerprinting,” to be identical to the cells taken from the patients. Then the newly generated ES cells were exposed to 2 signaling molecules as follows: an agonist in the Sonic hedgehog pathway and retinoic acid. When the resulting cells were placed on a laminin-coated surface, they grew neuronlike processes. With further maturation, 20% of the cells expressed a motor neuron marker. Some of the cells even expressed choline acetyltransferase (a marker for maturing motor neurons) and spinal cord progenitor markers. The authors were able to generate a significant number of motor neurons from cells taken from the skin of elderly patients with ALS. This article offers a glimpse of the future potential of the new paradigm; it may be possible to generate an essentially unlimited supply of autologous neurons of the same type that was affected by the disease. Interestingly, the viral transgenes that are used to transform the adult cells into ES cells are often silenced after they complete their job. Before any clinical application, it is important to fully study the fate of the viral transgenes in the resulting cells. However, even at this stage of the development of induced pluripotent stem cells, they can become an important tool for in vitro investigation of disease mechanisms and new therapies.